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The Surgery of Renal Transplantation
Symposium on Cardiac and Renal Surgery
The Surgery of Renal Transplantation
B. H. Stewart, M.D.
The basic surgical principles of renal transplantation were developed in laboratory animals by Alexis Carrel soon after the turn of this century.3 As transplantation in man has become standard therapy for renal failure during the past decade, the surgical techniques originally described by Merrill, Murray, Harrison, and Guilds have been further refined. In this report we will present those operations which are now felt by most surgeons to be procedures of choice in dealing with both donor and recipient, and will also present alternative methods of dealing with unusual or complicated situations.
DONOR OPERATIONS Living Donor Long-term results from well-matched related donors are superior to those achieved when non-related cadaver donors are used, and for this reason living donors, when available, are still the preferred source of kidneys for transplantation. Living donors must be well motivated, immunologically compatible with the potential recipient, and in good general health. Preoperative angiography is essential in planning the donor operation, which is done as an elective procedure. Intravenous hydration of the donor should be carried out during the night prior to surgery, and mannitol is given by injection during the early stages of the operation. The kidney is approached through an anterior subcostal incision; the opposite rectus muscle is also transected if the patient is heavily muscled or obese. Excellent exposure of the great vessels and renal vasculature is essential. After the colon is reflected medially, the kidney is gently mobilized, care being taken to preserve the renal capsule and, in particular, the vascular tissues surrounding the ureter. The ureter is dissected downward to the level of the iliac vessels, transected, and secured distally with a 2-0 silk ligature. The ureter is then observed closely, and transplantation is not carried out until the surgeon is assured of continuous and adequate urinary flow from the donor kidney. From the Department of Urology. The Cleveland Clinic Foundation Surgical Clinics of North America- Vol. 51, No.5, October 1971
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The renal artery and vein are then dissected free from surrounding structures, and all lumbar vessels that enter the renal vein are carefully isolated and ligated. On the left side the adrenal vein is transected and ligated, care being taken not to carry the dissection into the renal hilus or to damage the adrenal gland itself. Should the left renal artery be marginal in length, the aorta can be partially occluded and the artery transected at its point of take-off from the aorta. The aorta is then repaired with running 5-0 silk sutures, after which the vascular clamp is released and hemostasis confirmed. Renal venous length is always adequate on the left, allowing the renal vein to be transected and ligated with 1 or 2 heavy silk ligatures. The renal artery is occluded first, and then the vein, after which the kidney is removed and transferred to the perfusion table. There it is cooled in iced saline and the renal artery is irrigated with a perfusion solution until the venous effluent is clear. The kidney is then transferred to the adjoining room for transplantation. Arterial length is usually sufficient on the right side to allow division and ligation of the renal artery with two heavy silk ligatures as it emerges from the aorta. The right renal vein may be quite short, and in this event a partially occluding caval clamp is applied and the renal vein is transec ted with a small cuff of vena cava. The cava is then rapidly oversewn with 6-0 arterial silk and the clamp is released. After the kidney is removed and taken to the adjoining room for transplantation, meticulous attention is given to the donor renal fossa, where hemostasis is completed with electrocautery, silver clips, or ligatures. Small lymphatics may have been transected during the couse of the dissection, and these should all be secured before the abdomen is closed. The renal fossa is irrigated with neomycin solution, the area reperitonealized with running 3-0 silk sutures, and the wound closed in layers without drainage. Postoperative care is the same as for any major abdominal procedure.
Cadaver Donor Cadaver donors are of necessity utilized when a suitable living donor is not available. These have the added advantages of potentially supplying two kidneys at one operation and of eliminating live donor morbidity. Unfortunately, even with optimal tissue typing, results of cadaver donor transplantation do not yet approach those attained with well-matched living donors. Whenever possible, surgeons experienced in organ salvage procedures should remove cadaver donor kidneys. In the past, surgeons inexperienced in renal transplantation have unfortunately traumatized the renal vessels, capsule, or ureteral blood supply sufficiently to render some kidneys unsuitable for transplantation. In addition, the organ recovery team can note any unusual anatomical features and thereby better prepare the kidneys for perfusion and for transplantation itself. From an ethical standpoint, it is essential for death first to be declared by the donor's attending physicianY When death appears imminent, the organ recovery team is summoned and preparations are made for donor nephrectomy. If possible, vital signs are preserved by artificial
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means until the kidneys have been removed; all prospective donors should be maintained on intravenous heparin and mannitol to insure continued urinary output. In general, the best donors have been patients dying of massive cerebral trauma or hemorrhage. Patients dying with cancer or of prolonged shock or sepsis are unsuitable as kidney donors.9 Donor nephrectomy is performed in the operating room with all the instruments usually available for a major abdominal procedure. A vertical midline incision is made from the xiphoid process to the symphysis, and each kidney is exposed by reflecting the colon and small bowel contents, medially. The same precautions are observed as for live donor nephrectomy, and all renal arterial branches should be carefully identified. Should multiple renal arteries be present, a cuff of aorta should be removed, which will include all renal vessels and which will subsequently be anastomosed as an on-lay patch graft into the recipient's iliac artery.5, 7 Lower polar vessels should be handled with extreme caution, as trauma to these vessels may produce ischemic changes in the ureter, resulting in ureteral sloughing and extravasation of urine. Immediately after removal the kidneys are perfused and cooled to 4° C. with Ringer's lactate solution; they are then packed in iced saline slush,4 and transported immediately to the Belzer perfusion apparatus where continuous renal perfusion is instituted. 2 This presents no problem when the donor and recipient reside in the same hospital. Helicopter or jet aircraft transportation has been successfully employed between cities or even states when the hospital where the donor kidney is procured is located at a great distance from the transplant center. Kidneys should be removed within 1 hour after effective circulation in the donor has ceased, and should be placed on the organ perfusion machine within 3 to 4 hours after the initial perfusion and cooling. Subsequent viability testing and tissue typing while the kidney is on the machine allow at least another 24 hours to summon and properly prepare the recipient. After the recipient has been located and prepared for surgery, the kidney is removed from the perfusion apparatus and transported in sterile iced saline slush to the hospital of the recipient. Post perfusion ischemia times of 3 to 4 hours have been well tolerated in selected patients (see article by Magnusson and Kiser).
RECIPIENT OPERATIONS Preparation Bilateral nephrectomy has been successfully performed at the time of transplantation in some centers, but when cadaver kidneys are employed the patient's condition may not permit simultaneous nephrectomy and transplantation. For this reason we have routinely performed bilateral nephrectomy as an elective procedure at least 2 weeks prior to renal transplantation. l1 The patient is brought to optimal physical condition by dialysis and appropriate medication, and bilateral nephrectomy is carried out through a vertical midline abdominal incision from the xiphoid process to the level of the umbilicus. The midline incision de-
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creases operating time and minimizes blood loss. After entry of the abdominal cavity the left colon is reflected medially, the spleen and pancreas are retracted upward, and Gerota's fascia is opened over the anterior surface of the kidney. The dissection is kept as close to the kidney as possible, minimizing trauma to surrounding tissues. The entire renal pedicle is isolated by blunt dissection, the kidney delivered through Gerota's fascia, and the renal pedicle doubly clamped. The renal pedicle is then transected distal to the second clamp, and the pedicle doubly secured with heavy silk ligatures. The ureter is then transected just below the renal pelvis and ligated with a single 3-0 silk ligature. Hemostasis is meticulously completed with electrocautery, silver clips, or small ligatures. The renal fossa is irrigated with neomycin solution and the peritoneal incision is closed with interrupted or running 3-0 silk sutures. The procedure is then repeated on the right side, the liver and gall bladder being retracted upward and the right colon medially to gain satisfactory exposure. Meticulous hemostasis and careful reperitonealization minimizes the chance of postoperative hemorrhage in these poor-risk patients, where diffuse bleeding from small vessels is often an annoying complication. The incision is closed with sutures of heavy stainless steel wire or Ethiflex,':< and postoperative management is similar to that carried out after any major abdominal procedure. Early in our experience trans-cervical thymectomy was performed on a randomized series of patients at the same time as bilateral nephrectomy. There is some evidence that long-term survivors may do somewhat better with thymectomy than without, but this has not been sufficiently impressive to justify routine thymectomy as yet. Splenectomy has been performed in randomized patients at the time of nephrectomy, but to this date has offered no advantage in terms of recipient survival and is no longer employed.
Transplantation The recipient should be prepared and maintained on intermittent hemodialyses while waiting for transplantation. In selected recipients, an additional dialysis just prior to transplantation may be necessary, while the cadaver kidney is being maintained in a viable state on the Belzer preservation unit. Endotracheal anesthesia is employed, and all blood for transfusion is cleared of potassium by passage through a cation-exchange resin column. Under strictly aseptic technique, a No. 20 French Silastic catheter is passed, the bladder irrigated thoroughly with neomycin solution, and the catheter connected to a sterile, closed-system drainage apparatus. The entire abdomen is scrubbed with Betadinet solution, washed with tincture of merthiolate, and then sprayed with an adhesive to facilitate the application of a plastic skin drape.
';'Ethicon, Inc., Somerville, New Jersey tPurdue Frederick Co. & Affiliates, Yonkers, New York
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VASCULAR PREPARATION. The pelvic retroperitoneal space is entered through a curvilinear lower quadrant incision, transecting the anterior rectus sheath and dividing the ipsilateral rectus muscle at its insertion into the symphysis pubis. The external and internal oblique muscles and fascia are divided in line with the incision, and the inferior epigastric vessels are divided and doubly ligated. In the male patient, efforts should be made to preserve the spermatic cord, although this must be transected in some cases to gain optimal exposure.· The round ligament is always divided in the female patient. Retroperitoneal fatty tissues are gently dissected away from the iliac vessels, and an area is created in the iliac fossa to receive the donor kidney. Care should be taken to avoid unnecessary dissection in this area because of the risk of postoperative bleeding and infection. After initial exposure of the vessels, the blades of the Smith ring retractor 10 are fixed in place to give constant exposure of the entire iliac fossa. This allows the entire operation to be completed by the surgeon and a single assistant. The common, external, and internal iliac arteries are dissected free from surrounding lymphatic and areolar tissue. Care is taken to carefully ligate or fulgurate all lymphatic channels proximal and distal to the area of transplantation. The external iliac vein is also mobilized from the inguinal ligament up to the level of the entrance of the internal iliac vein, ligating all small venous tributaries. It is not always necessary to mobilize and divide the internal iliac vein, although in extremely obese or heavily muscled individuals, or with donor kidneys with a short renal vein, this may be a useful surgical maneuver. The internal iliac artery is then dissected down to the level of its major bifurcations, which are individually secured between ligatures of 2-0 silk and divided. The common iliac artery should be dissected upward to allow complete mobilization of the proximal 3 or 4 centimeters of this vessel. This allows the entire hypogastric artery to be brought around and upward in a gentle curve, avoiding subsequent kinking of the vascular anastomosis. Care should be taken not to extensively dissect the bifurcation of external and internal iliac arteries, where the arterial wall is thin and where excessive dissection can result in profuse hemorrhage. A small bulldog or serrafin vascular clamp is placed across the origin of the hypogastric artery, the distal end of the hypogastric artery is freshened, and the arterial lumen is irrigated thoroughly with dilute heparin solution. Should excessive atherosclerosis with plaque formation exist within the hypogastric artery, it is often better to perform an end-to-side anastomosis to the common or external iliac artery rather than risk the complications often encountered with extensive endarterectomy of the hypogastric artery. Bulldog clamps are then placed across the iliac vein proximal to the inguinal ligament and distal to the entrance of the internal iliac vein. Frequently two clamps will be necessary on the distal aspect of the vein to prevent venous flow into the segment used for the venous anastomosis. The donor kidney is then placed in the iliac fossa. An elliptical incision is made in the antero-Iateral aspect of the external iliac vein,
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and the renal vein is brought down for an end-to-side anastomosis with the external iliac vein, using running 6-0 arterial silk sutures. After completion of the venous anastomosis a small bulldog clamp may be placed across the renal vein and the iliac vein is allowed to fill, thus restoring iliac venous blood flow. The renal artery is then anastomosed end-to-end to the gently curving hypogastric artery with interrupted and running 6-0 arterial silk sutures. If the hypogastric artery is not suitable for anastomosis, then the common or external iliac artery can be cross clamped, an elliptical window created on the antero-Iateral wall, and an end-to-side anastomosis made between the spatulated end of the renal artery and the iliac vessel. Should multiple renal arteries be present, an on-lay patch graft anastomosis is performed, as illustrated in Figure 1. Bleeding from small vessels over the surface of the kidney or in the iliac fossa should be meticulously controlled. Should persistent capillary ooze become a problem, intravenous protamine, 25 to 50 mg., can be helpful. URETERAL ANASTOMOSIS. Ureteroneocystostomy is the procedure of choice in most cases, since the incidence of urinary extravasation following this procedure is much less than that following ureteroneopyelostomy or ureteroureterostomy (see p. 1137). Furthermore, if leakage does occur, the donor ureter can be resected, and a secondary anastomosis between the renal pelvis of the donor kidney and the patient's own ureter can be performed at a later date. 6 The donor ureter is carefully observed to confirm good blood supply, and its distal end is freshened and spatulated. The anterior bladder wall is mobilized and opened for a distance of 6 to 8 cm. to gain exposure of the interior of the bladder, and a second incision is made bluntly with a hemostat through the postero-Iateral wall of the bladder. This incision is then widened generously to receive the donor ureter, which is brought through the posterior bladder incision without angulation, leaving plenty
/
/ /
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I I I
I I
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Figure 1. An aortic cuff should be taken for on-lay patch graft anastomosis (a). A longitudinal Tshaped incision is made in the anterolateral wall of the common or external iliac artery (b). Edges are trimmed to enlarge the arteriotomy opening, and the iliac artery is endarterectomized if significant atheroma is present (c). The aortic cuff is anastomosed in place with running 5-0 arterial silk sutures, starting at distal apex of iliac arteriotomy (d).
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Figure 2. Ureterneocystostomy may be performed into the contralateral bladder wall when the donor kidney is disproportionately large and causes excessive compression of the ipsilateral bladder walL
of redundant ureter above so that there is no undue tension of the anastomosis. With the intravesical end of the ureter retracted upward, the bladder mucosa is elevated and a submucosal tunnel created downward for a distance of 4 cm. to a point just medial to the recipient's own ureteral orifice. Care is taken not to disturb the patient's own ureter during this part of the dissection. The ureter is then brought down through the submucosal tunnel and an elliptical anastomosis is performed between the ureter and the bladder mucosa and musculature, with interrupted 5-0 chronic catgut sutures. The cystotomy incision is then closed with a running 3-0 chromic catgut mucosal suture, followed by inverting seromuscular sutures of 2-0 chromic catgut to achieve a water-tight closure. Whenever possible, a third layer of inverting sutures is also employed, care being taken not to compromise the entrance of the ureter into the bladder. The abdominal incision is then closed without drainage after meticulous hemostasis and thorough irrigation. A single layer of heavy stainless steel wire sutures is used in most cases. A Silas tic Foley urethral catheter is connected to a closed drainage system and antibacterial coverage is maintained for 5 to 7 days following operation. When the donor kidney is much larger than the recipient's iliac fossa, as is the case when adult kidneys are used in small children, the lower pole of the kidney may so compress the lateral wall of the bladder as to totally obstruct the reimplanted ureter. 1 In such cases the bladder is mobilized across the midline posteriorly, and the ureter brought in through the opposite postero-Iateral wall of the bladder and down the interior of the bladder on the opposite side, to lie near the contralateral ureteral orifice (Fig. 2). This allows uninterrupted urinary flow, even
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though significant compression of the ipsilateral bladder wall may be present. Likewise, when large donor kidney vessels are implanted into a child, one must move up the great vessels to anastomose the vein end-toside into the lower vena cava, and the artery end-to-side into the lower aspect of the abdominal aorta. 10 This can usually be accomplished by a retroperitoneal approach, but the incision must be carried higher than in the usual adult procedure. Postoperative care should include reversed sterile precautions, aseptic catheter care, and abdominal compression over the area of the transplant for the first 24 to 48 hours. Immunosuppressive therapy is maintained and the patient progressively ambulated as tolerated. Intermittent hemodialysis during the period of postoperative attention may be necessary in some cases following cadaver kidney transplantation, although with better organ perfusion techniques this is now rarely necessary.
SUMMARY AND CONCLUSIONS A summary of the operative techniques currently employed in renal transplantation has been presented. Donor nephrectomy should be carried out whenever possible by an experienced organ recovery team, and all donor kidneys should be rapidly transported to an organ perfusion center where viability testing and tissue typing can be carried out. All renal arterial branches should be identified and preserved. In cadaver donors, a cuff of aorta should be excised when multiple renal arteries are present. Kidney transplant recipients should be carefully prepared and be in optimal condition for transplantation. Meticulous hemostasis should be observed throughout the transplant procedure, and all vascular anastomoses should be completed without obstruction or compromise of renal circulation. Ureteroneocystostomy is the preferred method of primary ureteral anastomosis. Vascular and ureteral procedures may have to be modified appropriately when great disparity between donor and recipient size exists. Observation of the fundamental principles of transplant surgery should significantly reduce the technical causes for failure in modern renal transplantation.
REFERENCES 1. Belzer, F. 0.: Personal communication, 1971. 2. Belzer, F. 0., and Kountz, S. L.: Preservation and transplantation of human cadaver kidneys: A two year experience. Ann. Surg., 172:394, 1970. 3. Carrel, A.: The ultimate result of a double nephrectomy and the replantation of one kidney. Gen. Exper. Med., 14:124, 1911. 4. Collins, G. M., Shugarman, M. D., and Terasaki, P. 1.: Kidney preservation for transportation. Lancet, 2:1219,1969. 5. Doak, P. B., et al.: Four years' experience with cadaveric renal transplantation. New Zealand Med. J., 73:117, 1971.
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6. Gifford, R W., Deodhar, S. D., Stewart, B. H., Nakamoto, S., Shibagaki, M., and KoHf, W. J.: Retransplantation after failure of first renal homografts. J.A.M.A., 199:1799, 1967. 7. Maclaurin, C. H.: Personal communication, 1971. 8. Merrill, J. P., Murray, J. E., Harrison, J. H., and Guild, W. R: Successful homotransplantation of the human kidney between identical twins. J.A.M.A., 160:277, 1956. 9. Straffon, R A., Kiser, W. S., Stewart, B. H., Hewitt, C. B., Gifford, R W., and Nakamoto, S.: Four years' clinical experience with 138 kidney transplants, Trans. Amer. Assoc. Genitourin. Surg., 59:49, 1967. 10. Straffon, R A., Stewart, B. H., Kiser, W. S., and Hewitt, C. B.: Surgery of renal transplantation. In Glenn, J. F., and Boyce, W. H., eds.: Urologic Surgery. New York, Harper and Row, 1969, p. 735. 11. Straffon, R A., Stewart, B. H., Kiser, W. S., and Hewitt, C. B.: Transplantation of kidneys from cadaver donors. Minn. Med., 51 : 1049, 1968. 12. Wasmuth, C. E., and Stewart, B. H.: Medical and legal aspects of human organ transplantation. The Cleveland Marshall Law Review, 14:422, 1965.
The Surgery of Renal Transplantation
B. H. Stewart, M.D.
The basic surgical principles of renal transplantation were developed in laboratory animals by Alexis Carrel soon after the turn of this century.3 As transplantation in man has become standard therapy for renal failure during the past decade, the surgical techniques originally described by Merrill, Murray, Harrison, and Guilds have been further refined. In this report we will present those operations which are now felt by most surgeons to be procedures of choice in dealing with both donor and recipient, and will also present alternative methods of dealing with unusual or complicated situations.
DONOR OPERATIONS Living Donor Long-term results from well-matched related donors are superior to those achieved when non-related cadaver donors are used, and for this reason living donors, when available, are still the preferred source of kidneys for transplantation. Living donors must be well motivated, immunologically compatible with the potential recipient, and in good general health. Preoperative angiography is essential in planning the donor operation, which is done as an elective procedure. Intravenous hydration of the donor should be carried out during the night prior to surgery, and mannitol is given by injection during the early stages of the operation. The kidney is approached through an anterior subcostal incision; the opposite rectus muscle is also transected if the patient is heavily muscled or obese. Excellent exposure of the great vessels and renal vasculature is essential. After the colon is reflected medially, the kidney is gently mobilized, care being taken to preserve the renal capsule and, in particular, the vascular tissues surrounding the ureter. The ureter is dissected downward to the level of the iliac vessels, transected, and secured distally with a 2-0 silk ligature. The ureter is then observed closely, and transplantation is not carried out until the surgeon is assured of continuous and adequate urinary flow from the donor kidney. From the Department of Urology. The Cleveland Clinic Foundation Surgical Clinics of North America- Vol. 51, No.5, October 1971
1123
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STEWART
The renal artery and vein are then dissected free from surrounding structures, and all lumbar vessels that enter the renal vein are carefully isolated and ligated. On the left side the adrenal vein is transected and ligated, care being taken not to carry the dissection into the renal hilus or to damage the adrenal gland itself. Should the left renal artery be marginal in length, the aorta can be partially occluded and the artery transected at its point of take-off from the aorta. The aorta is then repaired with running 5-0 silk sutures, after which the vascular clamp is released and hemostasis confirmed. Renal venous length is always adequate on the left, allowing the renal vein to be transected and ligated with 1 or 2 heavy silk ligatures. The renal artery is occluded first, and then the vein, after which the kidney is removed and transferred to the perfusion table. There it is cooled in iced saline and the renal artery is irrigated with a perfusion solution until the venous effluent is clear. The kidney is then transferred to the adjoining room for transplantation. Arterial length is usually sufficient on the right side to allow division and ligation of the renal artery with two heavy silk ligatures as it emerges from the aorta. The right renal vein may be quite short, and in this event a partially occluding caval clamp is applied and the renal vein is transec ted with a small cuff of vena cava. The cava is then rapidly oversewn with 6-0 arterial silk and the clamp is released. After the kidney is removed and taken to the adjoining room for transplantation, meticulous attention is given to the donor renal fossa, where hemostasis is completed with electrocautery, silver clips, or ligatures. Small lymphatics may have been transected during the couse of the dissection, and these should all be secured before the abdomen is closed. The renal fossa is irrigated with neomycin solution, the area reperitonealized with running 3-0 silk sutures, and the wound closed in layers without drainage. Postoperative care is the same as for any major abdominal procedure.
Cadaver Donor Cadaver donors are of necessity utilized when a suitable living donor is not available. These have the added advantages of potentially supplying two kidneys at one operation and of eliminating live donor morbidity. Unfortunately, even with optimal tissue typing, results of cadaver donor transplantation do not yet approach those attained with well-matched living donors. Whenever possible, surgeons experienced in organ salvage procedures should remove cadaver donor kidneys. In the past, surgeons inexperienced in renal transplantation have unfortunately traumatized the renal vessels, capsule, or ureteral blood supply sufficiently to render some kidneys unsuitable for transplantation. In addition, the organ recovery team can note any unusual anatomical features and thereby better prepare the kidneys for perfusion and for transplantation itself. From an ethical standpoint, it is essential for death first to be declared by the donor's attending physicianY When death appears imminent, the organ recovery team is summoned and preparations are made for donor nephrectomy. If possible, vital signs are preserved by artificial
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means until the kidneys have been removed; all prospective donors should be maintained on intravenous heparin and mannitol to insure continued urinary output. In general, the best donors have been patients dying of massive cerebral trauma or hemorrhage. Patients dying with cancer or of prolonged shock or sepsis are unsuitable as kidney donors.9 Donor nephrectomy is performed in the operating room with all the instruments usually available for a major abdominal procedure. A vertical midline incision is made from the xiphoid process to the symphysis, and each kidney is exposed by reflecting the colon and small bowel contents, medially. The same precautions are observed as for live donor nephrectomy, and all renal arterial branches should be carefully identified. Should multiple renal arteries be present, a cuff of aorta should be removed, which will include all renal vessels and which will subsequently be anastomosed as an on-lay patch graft into the recipient's iliac artery.5, 7 Lower polar vessels should be handled with extreme caution, as trauma to these vessels may produce ischemic changes in the ureter, resulting in ureteral sloughing and extravasation of urine. Immediately after removal the kidneys are perfused and cooled to 4° C. with Ringer's lactate solution; they are then packed in iced saline slush,4 and transported immediately to the Belzer perfusion apparatus where continuous renal perfusion is instituted. 2 This presents no problem when the donor and recipient reside in the same hospital. Helicopter or jet aircraft transportation has been successfully employed between cities or even states when the hospital where the donor kidney is procured is located at a great distance from the transplant center. Kidneys should be removed within 1 hour after effective circulation in the donor has ceased, and should be placed on the organ perfusion machine within 3 to 4 hours after the initial perfusion and cooling. Subsequent viability testing and tissue typing while the kidney is on the machine allow at least another 24 hours to summon and properly prepare the recipient. After the recipient has been located and prepared for surgery, the kidney is removed from the perfusion apparatus and transported in sterile iced saline slush to the hospital of the recipient. Post perfusion ischemia times of 3 to 4 hours have been well tolerated in selected patients (see article by Magnusson and Kiser).
RECIPIENT OPERATIONS Preparation Bilateral nephrectomy has been successfully performed at the time of transplantation in some centers, but when cadaver kidneys are employed the patient's condition may not permit simultaneous nephrectomy and transplantation. For this reason we have routinely performed bilateral nephrectomy as an elective procedure at least 2 weeks prior to renal transplantation. l1 The patient is brought to optimal physical condition by dialysis and appropriate medication, and bilateral nephrectomy is carried out through a vertical midline abdominal incision from the xiphoid process to the level of the umbilicus. The midline incision de-
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STEWART
creases operating time and minimizes blood loss. After entry of the abdominal cavity the left colon is reflected medially, the spleen and pancreas are retracted upward, and Gerota's fascia is opened over the anterior surface of the kidney. The dissection is kept as close to the kidney as possible, minimizing trauma to surrounding tissues. The entire renal pedicle is isolated by blunt dissection, the kidney delivered through Gerota's fascia, and the renal pedicle doubly clamped. The renal pedicle is then transected distal to the second clamp, and the pedicle doubly secured with heavy silk ligatures. The ureter is then transected just below the renal pelvis and ligated with a single 3-0 silk ligature. Hemostasis is meticulously completed with electrocautery, silver clips, or small ligatures. The renal fossa is irrigated with neomycin solution and the peritoneal incision is closed with interrupted or running 3-0 silk sutures. The procedure is then repeated on the right side, the liver and gall bladder being retracted upward and the right colon medially to gain satisfactory exposure. Meticulous hemostasis and careful reperitonealization minimizes the chance of postoperative hemorrhage in these poor-risk patients, where diffuse bleeding from small vessels is often an annoying complication. The incision is closed with sutures of heavy stainless steel wire or Ethiflex,':< and postoperative management is similar to that carried out after any major abdominal procedure. Early in our experience trans-cervical thymectomy was performed on a randomized series of patients at the same time as bilateral nephrectomy. There is some evidence that long-term survivors may do somewhat better with thymectomy than without, but this has not been sufficiently impressive to justify routine thymectomy as yet. Splenectomy has been performed in randomized patients at the time of nephrectomy, but to this date has offered no advantage in terms of recipient survival and is no longer employed.
Transplantation The recipient should be prepared and maintained on intermittent hemodialyses while waiting for transplantation. In selected recipients, an additional dialysis just prior to transplantation may be necessary, while the cadaver kidney is being maintained in a viable state on the Belzer preservation unit. Endotracheal anesthesia is employed, and all blood for transfusion is cleared of potassium by passage through a cation-exchange resin column. Under strictly aseptic technique, a No. 20 French Silastic catheter is passed, the bladder irrigated thoroughly with neomycin solution, and the catheter connected to a sterile, closed-system drainage apparatus. The entire abdomen is scrubbed with Betadinet solution, washed with tincture of merthiolate, and then sprayed with an adhesive to facilitate the application of a plastic skin drape.
';'Ethicon, Inc., Somerville, New Jersey tPurdue Frederick Co. & Affiliates, Yonkers, New York
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VASCULAR PREPARATION. The pelvic retroperitoneal space is entered through a curvilinear lower quadrant incision, transecting the anterior rectus sheath and dividing the ipsilateral rectus muscle at its insertion into the symphysis pubis. The external and internal oblique muscles and fascia are divided in line with the incision, and the inferior epigastric vessels are divided and doubly ligated. In the male patient, efforts should be made to preserve the spermatic cord, although this must be transected in some cases to gain optimal exposure.· The round ligament is always divided in the female patient. Retroperitoneal fatty tissues are gently dissected away from the iliac vessels, and an area is created in the iliac fossa to receive the donor kidney. Care should be taken to avoid unnecessary dissection in this area because of the risk of postoperative bleeding and infection. After initial exposure of the vessels, the blades of the Smith ring retractor 10 are fixed in place to give constant exposure of the entire iliac fossa. This allows the entire operation to be completed by the surgeon and a single assistant. The common, external, and internal iliac arteries are dissected free from surrounding lymphatic and areolar tissue. Care is taken to carefully ligate or fulgurate all lymphatic channels proximal and distal to the area of transplantation. The external iliac vein is also mobilized from the inguinal ligament up to the level of the entrance of the internal iliac vein, ligating all small venous tributaries. It is not always necessary to mobilize and divide the internal iliac vein, although in extremely obese or heavily muscled individuals, or with donor kidneys with a short renal vein, this may be a useful surgical maneuver. The internal iliac artery is then dissected down to the level of its major bifurcations, which are individually secured between ligatures of 2-0 silk and divided. The common iliac artery should be dissected upward to allow complete mobilization of the proximal 3 or 4 centimeters of this vessel. This allows the entire hypogastric artery to be brought around and upward in a gentle curve, avoiding subsequent kinking of the vascular anastomosis. Care should be taken not to extensively dissect the bifurcation of external and internal iliac arteries, where the arterial wall is thin and where excessive dissection can result in profuse hemorrhage. A small bulldog or serrafin vascular clamp is placed across the origin of the hypogastric artery, the distal end of the hypogastric artery is freshened, and the arterial lumen is irrigated thoroughly with dilute heparin solution. Should excessive atherosclerosis with plaque formation exist within the hypogastric artery, it is often better to perform an end-to-side anastomosis to the common or external iliac artery rather than risk the complications often encountered with extensive endarterectomy of the hypogastric artery. Bulldog clamps are then placed across the iliac vein proximal to the inguinal ligament and distal to the entrance of the internal iliac vein. Frequently two clamps will be necessary on the distal aspect of the vein to prevent venous flow into the segment used for the venous anastomosis. The donor kidney is then placed in the iliac fossa. An elliptical incision is made in the antero-Iateral aspect of the external iliac vein,
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and the renal vein is brought down for an end-to-side anastomosis with the external iliac vein, using running 6-0 arterial silk sutures. After completion of the venous anastomosis a small bulldog clamp may be placed across the renal vein and the iliac vein is allowed to fill, thus restoring iliac venous blood flow. The renal artery is then anastomosed end-to-end to the gently curving hypogastric artery with interrupted and running 6-0 arterial silk sutures. If the hypogastric artery is not suitable for anastomosis, then the common or external iliac artery can be cross clamped, an elliptical window created on the antero-Iateral wall, and an end-to-side anastomosis made between the spatulated end of the renal artery and the iliac vessel. Should multiple renal arteries be present, an on-lay patch graft anastomosis is performed, as illustrated in Figure 1. Bleeding from small vessels over the surface of the kidney or in the iliac fossa should be meticulously controlled. Should persistent capillary ooze become a problem, intravenous protamine, 25 to 50 mg., can be helpful. URETERAL ANASTOMOSIS. Ureteroneocystostomy is the procedure of choice in most cases, since the incidence of urinary extravasation following this procedure is much less than that following ureteroneopyelostomy or ureteroureterostomy (see p. 1137). Furthermore, if leakage does occur, the donor ureter can be resected, and a secondary anastomosis between the renal pelvis of the donor kidney and the patient's own ureter can be performed at a later date. 6 The donor ureter is carefully observed to confirm good blood supply, and its distal end is freshened and spatulated. The anterior bladder wall is mobilized and opened for a distance of 6 to 8 cm. to gain exposure of the interior of the bladder, and a second incision is made bluntly with a hemostat through the postero-Iateral wall of the bladder. This incision is then widened generously to receive the donor ureter, which is brought through the posterior bladder incision without angulation, leaving plenty
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Figure 1. An aortic cuff should be taken for on-lay patch graft anastomosis (a). A longitudinal Tshaped incision is made in the anterolateral wall of the common or external iliac artery (b). Edges are trimmed to enlarge the arteriotomy opening, and the iliac artery is endarterectomized if significant atheroma is present (c). The aortic cuff is anastomosed in place with running 5-0 arterial silk sutures, starting at distal apex of iliac arteriotomy (d).
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Figure 2. Ureterneocystostomy may be performed into the contralateral bladder wall when the donor kidney is disproportionately large and causes excessive compression of the ipsilateral bladder walL
of redundant ureter above so that there is no undue tension of the anastomosis. With the intravesical end of the ureter retracted upward, the bladder mucosa is elevated and a submucosal tunnel created downward for a distance of 4 cm. to a point just medial to the recipient's own ureteral orifice. Care is taken not to disturb the patient's own ureter during this part of the dissection. The ureter is then brought down through the submucosal tunnel and an elliptical anastomosis is performed between the ureter and the bladder mucosa and musculature, with interrupted 5-0 chronic catgut sutures. The cystotomy incision is then closed with a running 3-0 chromic catgut mucosal suture, followed by inverting seromuscular sutures of 2-0 chromic catgut to achieve a water-tight closure. Whenever possible, a third layer of inverting sutures is also employed, care being taken not to compromise the entrance of the ureter into the bladder. The abdominal incision is then closed without drainage after meticulous hemostasis and thorough irrigation. A single layer of heavy stainless steel wire sutures is used in most cases. A Silas tic Foley urethral catheter is connected to a closed drainage system and antibacterial coverage is maintained for 5 to 7 days following operation. When the donor kidney is much larger than the recipient's iliac fossa, as is the case when adult kidneys are used in small children, the lower pole of the kidney may so compress the lateral wall of the bladder as to totally obstruct the reimplanted ureter. 1 In such cases the bladder is mobilized across the midline posteriorly, and the ureter brought in through the opposite postero-Iateral wall of the bladder and down the interior of the bladder on the opposite side, to lie near the contralateral ureteral orifice (Fig. 2). This allows uninterrupted urinary flow, even
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though significant compression of the ipsilateral bladder wall may be present. Likewise, when large donor kidney vessels are implanted into a child, one must move up the great vessels to anastomose the vein end-toside into the lower vena cava, and the artery end-to-side into the lower aspect of the abdominal aorta. 10 This can usually be accomplished by a retroperitoneal approach, but the incision must be carried higher than in the usual adult procedure. Postoperative care should include reversed sterile precautions, aseptic catheter care, and abdominal compression over the area of the transplant for the first 24 to 48 hours. Immunosuppressive therapy is maintained and the patient progressively ambulated as tolerated. Intermittent hemodialysis during the period of postoperative attention may be necessary in some cases following cadaver kidney transplantation, although with better organ perfusion techniques this is now rarely necessary.
SUMMARY AND CONCLUSIONS A summary of the operative techniques currently employed in renal transplantation has been presented. Donor nephrectomy should be carried out whenever possible by an experienced organ recovery team, and all donor kidneys should be rapidly transported to an organ perfusion center where viability testing and tissue typing can be carried out. All renal arterial branches should be identified and preserved. In cadaver donors, a cuff of aorta should be excised when multiple renal arteries are present. Kidney transplant recipients should be carefully prepared and be in optimal condition for transplantation. Meticulous hemostasis should be observed throughout the transplant procedure, and all vascular anastomoses should be completed without obstruction or compromise of renal circulation. Ureteroneocystostomy is the preferred method of primary ureteral anastomosis. Vascular and ureteral procedures may have to be modified appropriately when great disparity between donor and recipient size exists. Observation of the fundamental principles of transplant surgery should significantly reduce the technical causes for failure in modern renal transplantation.
REFERENCES 1. Belzer, F. 0.: Personal communication, 1971. 2. Belzer, F. 0., and Kountz, S. L.: Preservation and transplantation of human cadaver kidneys: A two year experience. Ann. Surg., 172:394, 1970. 3. Carrel, A.: The ultimate result of a double nephrectomy and the replantation of one kidney. Gen. Exper. Med., 14:124, 1911. 4. Collins, G. M., Shugarman, M. D., and Terasaki, P. 1.: Kidney preservation for transportation. Lancet, 2:1219,1969. 5. Doak, P. B., et al.: Four years' experience with cadaveric renal transplantation. New Zealand Med. J., 73:117, 1971.
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6. Gifford, R W., Deodhar, S. D., Stewart, B. H., Nakamoto, S., Shibagaki, M., and KoHf, W. J.: Retransplantation after failure of first renal homografts. J.A.M.A., 199:1799, 1967. 7. Maclaurin, C. H.: Personal communication, 1971. 8. Merrill, J. P., Murray, J. E., Harrison, J. H., and Guild, W. R: Successful homotransplantation of the human kidney between identical twins. J.A.M.A., 160:277, 1956. 9. Straffon, R A., Kiser, W. S., Stewart, B. H., Hewitt, C. B., Gifford, R W., and Nakamoto, S.: Four years' clinical experience with 138 kidney transplants, Trans. Amer. Assoc. Genitourin. Surg., 59:49, 1967. 10. Straffon, R A., Stewart, B. H., Kiser, W. S., and Hewitt, C. B.: Surgery of renal transplantation. In Glenn, J. F., and Boyce, W. H., eds.: Urologic Surgery. New York, Harper and Row, 1969, p. 735. 11. Straffon, R A., Stewart, B. H., Kiser, W. S., and Hewitt, C. B.: Transplantation of kidneys from cadaver donors. Minn. Med., 51 : 1049, 1968. 12. Wasmuth, C. E., and Stewart, B. H.: Medical and legal aspects of human organ transplantation. The Cleveland Marshall Law Review, 14:422, 1965.